A patient with advanced venous insufficiency is confined following orthopedic surgery. How can the nurse best prevent skin breakdown in the patient's lower extremities?
A) Ensure that the patient's heels are protected and supported.
B) Closely monitor the patient's serum albumin and prealbumin levels.
C) Perform gentle massage of the patient's lower legs, as tolerated.
D) Perform passive range-of-motion exercises once per shift.
Ans: A
Feedback:
If the patient is on bed rest, it is important to relieve pressure on the heels to prevent pressure ulcerations, since the heels are among the most vulnerable body regions. Monitoring blood work does not directly prevent skin breakdown, even though albumin is related to wound healing. Massage is not normally indicated and may exacerbate skin breakdown. Passive range- of-motion exercises do not directly reduce the risk of skin breakdown.
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